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Helicobacter pylori (HP) is a causative agent in gastric cancer (GC). 1 In the United States, HP is more prevalent in racial and ethnic minorities, including African Americans, Asian Americans, Latinos, and immigrants, the same groups that are more likely to develop and die from GC. 2 Although screening for HP is not presently performed in the United States, there are plausible benefits to doing so, because HP is considered a group 1 carcinogen by the World Health Organization, and its link to GC parallels that of human papilloma virus and cervical cancer. 1 HP eradication as a means of preventing GC also fulfils the Wilson and Jungner criteria for a successful screening program, and literature has consistently demonstrated that HP eradication reduces GC risk and death from GC. 3 In fact, in countries with a high burden of GC, HP eradication is considered primary prevention for GC. As such, targeted HP testing in the United States may reduce GC burden in high-risk groups. 4 We evaluate the results of community-based HP testing in an at-risk, underserved population., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the risk of optic neuritis (ON) after mRNA Coronavirus Disease 2019 (COVID-19) vaccine administration., Design: U.S. National aggregate database retrospective cohort study., Participants: Patients were placed into cohorts based on mRNA COVID-19 vaccination status (no vaccine and positive history of COVID-19 infection, 1 vaccine, or 2 vaccines received) from December 2020 to June 2022. Two control cohorts were created with patients vaccinated against influenza or tetanus, diphtheria, and pertussis (Tdap) from June 2018 to December 2019. Patients with any history of ON or significant risk factors for ON development including infectious, inflammatory, and neoplastic diseases were excluded., Methods: A large deidentified database was queried for the Common Procedural Technology codes for immunization encounters specific to first dose and second dose of mRNA COVID-19 vaccine, influenza, or Tdap. Cohorts were 1:1 propensity score matched on age, sex, race, and ethnicity. The risk of ON development after vaccination was calculated and compared for all 5 cohorts with 95% confidence intervals (CIs) reported., Main Outcome Measures: Risk ratio (RR) of ON 21 days after vaccination (or COVID-19 infection) and incidence of ON per 100 000 individuals., Results: After matching, the first dose COVID-19 and influenza vaccine cohorts (n = 1 678 598, mean age [standard deviation] at vaccination of 45.5 [23.3] years and 43.2 [25.5] years, 55% female) the RR of developing ON was 0.44 (95% CI, 0.28-0.80). The first dose of COVID-19 and Tdap vaccinations (n = 797 538, mean age 38.9 [20.0] years, 54.2% female) cohort had 10 and 16 patients develop ON (RR, 0.63; 95% CI, 0.28-1.38). Comparison of COVID-19-vaccinated patients (n = 3 698 848, 48.2 [21.5] years, 54.7% female) to unvaccinated and COVID-19-infected patients (n = 3 698 848, 49.6 [22.0] years, 55.2% female) showed 49 and 506 patients developing ON, respectively (RR, 0.09; 95% CI, 0.07-0.12). The incidence per 100 000 for ON was 1 in the first dose COVID-19 vaccine cohort, 2 in the influenza cohort, and 2 in the Tdap cohort, and 14 in the COVID-19-infected and unvaccinated cohorts., Conclusions: Risk of ON after mRNA COVID-19 vaccination is rare and comparable to Tdap vaccination, decreased compared with influenza vaccination, and decreased compared with COVID-19 infection in the absence of vaccination., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: With the obesity epidemic within the United States, the prevalence of idiopathic intracranial hypertension (IIH) is predicted to rise. IIH prevalence and racial disparities have rarely been reported in the United States. The purpose of this study was to evaluate the prevalence of IIH in a large national database while stratifying by sex, age, race, and ethnicity., Methods: This was a cross-sectional epidemiologic evaluation conducted in the TriNetX US Collaborative network using data from 2015 to 2022. Patients with an International Classification of Diseases code of IIH and papilledema or unspecified papilledema were included in the study. Any secondary cause of intracranial hypertension including cerebral neoplasms and hydrocephalus were excluded from the study. IIH trends were later compared with TriNetX cohort obesity trends. Prevalence and prevalence odds ratios (ORs) were calculated in Microsoft Excel and R Studio., Results: Among 85 million patients in this database, a 1.35 times increase in the prevalence of IIH occurred between 2015 and 2022 from 7.3 (95% CI 6.9-7.7) individuals per 100,000 to 9.9 (95% CI 9.5-10.3) individuals per 100,000 in 2022. In 2022, Black female individuals had the highest prevalence of IIH with 22.7 individuals per 100,000 compared with the 13.7 White female individuals per 100,000. Patients aged 11-17 years showed the largest growth of IIH prevalence with female individuals increasing by 10 individuals per 100,000 by 2022. Overall, Black and Hispanic patients had the largest prevalence OR of IIH at 1.66 (95% CI 1.49-1.85) and 1.33 (95% CI 1.14-1.56), respectively, compared with White female patients., Discussion: IIH is a rapidly increasing health care concern for the US population, particularly among adolescent patients. Black and Hispanic female individuals are most predominately affected by this incapacitating disorder.

Objective: The World Professional Association for Transgender Health Standards of Care Version 7 recommended that before initiating gender-affirming hormone therapy (GAHT), patients should seek a psychosocial evaluation from a mental health professional documenting a diagnosis of persistent gender dysphoria. The Endocrine Society published guidelines in 2017 recommending against an obligatory psychosocial evaluation, which was affirmed in the recently published World Professional Association for Transgender Health Standards of Care Version 8 from 2022. Little is known about how endocrinologists ensure appropriate psychosocial assessment for their patients. This study assessed the protocols and characteristics of U.S.-based adult endocrinology clinics that prescribe GAHT., Methods: An anonymous electronic survey sent to members of a professional organization and the "Endocrinologists" Facebook group was responded by 91 practicing board-certified adult endocrinologists who prescribe GAHT., Results: Thirty-one states were represented by the respondents. Overall, 83.1% of GAHT-prescribing endocrinologists reported accepting Medicaid. They reported working in university practices (28.4%), community practices (22.7%), private practices (27.3%), and other practice settings (21.6%). Overall, 42.9% of the respondents reported that their practice required documentation of a psychosocial evaluation from a mental health professional before initiating GAHT., Conclusion: Endocrinologists who prescribe GAHT are divided about requiring a baseline psychosocial evaluation before prescribing GAHT. Further work is needed to understand the impact of psychosocial assessment on patient care and facilitate the uptake of new guidelines into clinical practice., Competing Interests: Disclosure The authors have no multiplicity of interest to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Objective: This 2023 updated protocol summarizes the American Association of Clinical Endocrinology's (AACE's) new framework for the development of clinical practice guidelines and other guidance documents that includes changes to methodology, processes, and policies., Methods: AACE has critically reviewed its development processes for guidance documents over the last several years against the National Academy of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines and the Council of Medical Specialty Societies Principles for Development of Specialty Society Clinical Guidelines to determine areas for improvement., Results: The new AACE framework for development of guidance documents incorporates many changes, including a revised conflicts of interest (COI) policy; strengthened commitment to collection of disclosures and management of relevant COI during development; open calls to membership for authors; new requirements for authors; new diversity, equity, and inclusion (DEI) policy; new empanelment process that incorporates consideration of DEI; and adoption of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to increase the quality of evidence assessment and standardize recommendation grades and statements, among other improvements., Conclusions: AACE has revised its policies and adopted a completely new methodology for guideline development in support of the mission to elevate the practice of clinical endocrinology to improve patient care. With the use of an evidence-based medicine framework and by continually assessing and improving its processes for development of guidance, AACE strives to deliver trustworthy, unbiased, and up-to-date information that ensures clinician and patient confidence in AACE content. Further, AACE hopes that these enhancements foster a more collaborative approach to development and increase engagement with the worldwide medical community to improve global health., Competing Interests: Disclosures R.C. is the current chair of the AACE CPG Oversight Committee, a member of the AACE Board of Directors, and in leadership positions at the American Medical Association, Western Endocrine Alliance, American Federation of Medical Research, Association of Program Directors in Endocrinology, Diabetes and Metabolism, and Endocrine Society. J.M. is the current vice-chair of the AACE CPG Oversight Committee and in a leadership position at the Georgia Society of Endocrinology. T.H. is on the advisory board (no financial compensation) for Horizon therapeutics and a consultant for Acella (no financial compensation). S.J. is editor-in-chief of AACE Clinical Case Reports. D.C.L. is in leadership positions at the American Diabetes Association, Association of Program Directors in Endocrinology, Diabetes and Metabolism, and Endocrine Society. S.L.W. is a past president of AACE and former chair of the AACE CPG Oversight Committee, and receives research support and is a national or overall principal investigator for Novo Nordisk. M.B., D.C., and C.S. have nothing to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Introduction: Food insecurity is a major public health problem in the United States which was exacerbated by the COVID-19 pandemic. We used a multi-method approach to understand barriers and facilitators to implementing food insecurity screening and referrals at safety net health care clinics in Los Angeles County before the pandemic., Methods: In 2018, we surveyed 1013 adult patients across eleven safety-net clinic waiting rooms in Los Angeles County. Descriptive statistics were generated to characterize food insecurity status, attitudes toward receiving food assistance, and use of public assistance programs. Twelve interviews with clinic staff explored effective and sustainable approaches to food insecurity screening and referral., Results: Patients welcomed the opportunity to access food assistance in the clinic setting; 45% preferred discussing food issues directly with the doctor. Missed opportunities to screen for food insecurity and refer patients to food assistance were identified at the clinic level. Barriers to these opportunities included: competing demands on staff and clinic resources, difficulty establishing referral pathways, and doubts surrounding data., Discussion: Integrating food insecurity assessment in clinical settings requires infrastructure support, staff training, clinic buy-in, and more coordination and oversight from local government, health center entities, and public health agencies., Competing Interests: Conflicts of interest: None., (© Copyright by the American Board of Family Medicine.)

Objective: Counseling patients about nutrition significantly improves chronic disease outcomes. Endocrinologists are uniquely positioned to educate patients regarding nutrition. The purpose of this study was to define the current state of nutrition education in endocrinology fellowship programs in the United States and assess the needs for future nutrition training., Methods: Endocrinology program directors were surveyed via an online questionnaire between February and April 2021., Results: Thirty-eight program directors responded (25% response rate) to the survey. Twenty-two (58%) programs offered nutrition education. Existing nutrition education offerings were 1 to 5 total hours (13, 34%), primarily didactic (20, 53%), and often led by registered dietitian nutritionists (15, 39%). Only 3 (8%) programs rated their current nutrition education as extremely effective; 95% of respondents believed that further nutrition education was needed. According to respondents, the ideal nutrition education for endocrine trainees should be 1 to 5 total hours (19, 50%) over multiple sessions (25, 66%), be interactive (24, 63%), and be led by registered dietitian nutritionists (26, 68%). The most important topics for independent practice included diet-related behavior modification (21, 55%), components of a healthful diet (19, 50%), and energy expenditure/intake (18, 47%)., Conclusion: Although the majority of the program directors believe that further nutrition education is needed, almost half of the surveyed programs do not offer such training. Programs that offer nutrition education primarily rely on a didactic format. There is an unmet need for interactive, multidisciplinary nutrition education in these programs., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Abstract: The Coronavirus Disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome-coronavirus-2, has claimed 5,587,549 lives worldwide as of January 20, 2022. Fortunately, large-scale vaccination can mitigate the impact of COVID-19 by making the disease milder and less common. Although 75.2% of the United States population has received at least 1 dose of a COVID-19 vaccines thus far, concerns regarding vaccine side effects have contributed to vaccine hesitancy. Furthermore, nearly 50% of adults in the United States are concerned not only about side effects, but about their downstream impact, including missed work.The goal of this cross-sectional study was to investigate the effect of messenger RNA vaccine adverse effects on the propensity to miss work among employees associated with a single, large academic health center.Using Qualtrics, all employees, including faculty, staff, and trainees, of 5 large departments were surveyed to determine whether they received the COVID-19 vaccine and which type, and any symptoms they experienced after receipt of either vaccine dose. We hypothesized that vaccine recipients would be more likely to miss work or feel sick enough to miss work following the second dose.Thirty-seven percent of respondents experienced events severe enough that they needed to miss work from either of the doses, with the majority (27.8%) related to the second dose. These findings are consistent with and expand on the results from the phase 3 trials for Pfizer-BionTech and Moderna, which showed that vaccine side effects were more common after the second dose than after the first dose. Our statistically significant finding was more common among Asians, women, trainees/house staff, and nonphysician clinical employees.With an increasing number of individuals taking the vaccine, employers will need to account for the impact of adverse effects on their employees' ability to work. These findings will further help organizations better plan for staffing as vaccinations increase to mitigate the spread of COVID-19., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Stressors associated with COVID-19 pandemic stay-at-home orders are associated with increased depression and anxiety and decreased physical activity. Given that physical activity and time spent outdoors in nature are associated with improved mental health, we examined the longitudinal association of these variables during the pandemic. Over 20,000 adults who participated in the U.S. Kaiser Permanente Research Bank, did not report COVID-19 symptoms, and responded to an online baseline and 3 follow-up surveys over approximately 3 months formed the cohort. Physical activity was assessed from a modified survey, time spent outdoors was assessed from one question, and anxiety and depression scores were assessed from validated instruments. Almost 60% were women, 82.8% were non-Hispanic white, and more than 93% of respondents were over the age of 50. Less in-person contact with friends and visiting crowded places was highly prevalent (>80%) initially and decreased somewhat (>70%). Participants in the lowest physical activity category (no physical activity) had the highest depression and anxiety scores compared to each successive physical activity category (p < 0.001). Spending less time outdoors was associated with higher depression and anxiety scores. This effect was greater for participants in the younger age categories compared with older age categories. The effect of less time spent outdoors on anxiety (p = 0.012) and depression (p < 0.001) scores was smaller for males than females. Results suggest that physical activity and time outdoors is associated with better mental health. People should be encouraged to continue physical activity participation during public health emergencies., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

All people need to engage in routine physical activity and children require it daily. Playgrounds are settings designed for children to be physically active, yet there has been little research assessing which play elements and structures are associated with more moderate-to-vigorous physical activity (MVPA) among both youth and adults. We conducted a national study of neighborhood parks with the goal of identifying factors that promote more MVPA. We selected a nationally representative sample of 162 parks between 3 and 22 acres in 25 U.S. cities with a population >100,000. We used direct observation to measure MVPA in 147 playgrounds during spring and summer of 2016, documented playground characteristics and assessed hours of use and MVPA by age group and gender. We analyzed data using descriptive statistics and generalized linear models. The most common play elements and structures were slides and ladders (92% of parks) and swings (81%); elements supporting balancing, crawling, spinning, sand and water play were in <30% of playgrounds. Each additional play element was associated with about 50% more users and 50% more MVPA. Spinning structures and splash pads were associated with more playground use and more MVPA. Playgrounds with signage advertising park programs and on-site restrooms had more person-hours of use, but only half the parks had restrooms and <30% had signage. To address insufficient physical activity, upgrades to playgrounds should include restrooms, structures that support a wide variety of movements, and elements that also encourage adults to be active., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Many Americans fail to meet physical activity guidelines. We investigated whether this failure is due in part to a lack of free time., Methods: We analyzed data from the American Time Use Survey, 2014 through 2016, with 32,048 respondents aged 15 years or older, categorizing every activity during a 24-hour period. Free or leisure time includes time spent socializing, being entertained, in sports and recreation activities, volunteering, in religious activities, taking classes for personal interest, and in associated travel time. Working in the labor market, education (unless only for personal interest), household work and home production (cooking, cleaning, child care, shopping), or self-care (sleeping, eating, grooming) are not free time. We stratified by sociodemographic characteristics, health, and body mass index, and we calculated descriptive statistics adjusted for the multistage sampling design., Results: Americans averaged more than 5 hours (>300 minutes) of free time per day; no subgroup reported having less than 4.5 hours (270 minutes) of free time. Men had more free time (mean [standard deviation], 356 [3] min/d) and spent more on leisure time physical activity (mean [SD], 24 [3] min/d) than women did (free time mean [SD], 318 [2] min/d, P < .001; and leisure time physical activity mean [SD], 14 [1] min/d, P < .001). Compared with those with a higher income and a college education, those with income below 185% of federal poverty guidelines and those with a high school education reported more free time but spent more time on television, movies, and other screen time and less on physical activity (all comparisons P < .001)., Conclusion: Lack of free time is not responsible for low levels of leisure time physical activity at the population level.

Objectives: The aim of the study is to assess the use and levels of moderate-to-vigorous physical activity (MVPA) occurring in innovative playgrounds in London vs. traditional playgrounds in the US in neighborhoods with a similar population density., Study Design: This is a cross-sectional observational study., Methods: We selected a sample of London playgrounds based on their innovative design. One group of eight playgrounds was matched to the US playgrounds by size and population density; a second group of very large London playgrounds was matched only by population density. Playground use and person-hours of MVPA were measured using direct observation at similar times of the day and days of the week in all locations., Results: The number of playground visit hours was 58% higher in London than in the US (394 vs 249). The matched London playgrounds had 37.8% more children and 129% more adults who were, respectively, engaging in 90% and 116% more MVPA. While the London playgrounds were nearly 8.5 times larger than the US ones, they attracted a total of 5.8 times more visitors (1399 vs 243, P < .0001), and this included 10 times as many adults (679 vs. 66, P < .0001) and 7.5 times more seniors (23 vs. 3). The London playgrounds included more amenities targeting adults., Conclusions: The design of an innovative playground was associated with the amount of MVPA in similar-sized playgrounds, but the size of the playground was more strongly associated with the number of visitors. It is as important to design playgrounds for adults as it is for children to increase visit hours., (Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

The United States lacks surveillance to monitor park use and conditions. The purpose of this study was to use the System for Observing Play and Recreation in Communities (SOPARC) as a surveillance tool to describe the conditions, user characteristics, and physical activity of a national sample of neighborhood parks at two time points. Using a stratified multistage sampling strategy, a representative sample of 174 neighborhood parks in 25 major United States' cities were selected. During 2014 and 2016, park-related use, conditions, and physical activity were assessed using SOPARC in 169 parks. Overall, 74,106 park users were observed at baseline and 69,150 park users were observed two years later (p = 0.37). There were persistent disparities in park use by gender and age, with disproportionately more male than female users in each age group (child, teenager, adult, older adult). Older adults used the park less than other age groups. Almost two-thirds of park users were observed being sedentary (61.9% in 2014, 60.7% in 2016), followed by moderate (30.8%, 32.0%) and vigorous (7.3%, 7.3%) activity. Empty target areas increased over two years (75.3%, 77.6%; p = 0.01) and those that were equipped (2.6%, 1.2%; p = 0.0003), accessible (95.4%, 94.3%; p = 0.01), and organized (2.6%, 1.7%; p = 0.01) decreased. Areas that were usable (97.5%, 97.4%) or provided supervised activities (2.0%, 2.4%) did not change significantly. The findings demonstrate the value of SOPARC as a surveillance tool, identify user groups under represented at parks, and suggest an opportunity to encourage more park-based physical activity among park visitors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The current study examined racial/ethnic differences in use of parks and park facilities and features and self-reported park use and perceptions. We conducted observations in a nationally representative sample of 193 neighborhood parks in 27 US cities over a 1-week period between April and August of 2016 using the System of Observing Play and Recreation in Communities (SOPARC). To determine the propensity of different racial/ethnic groups to use parks relative to expectation based on their representation in the surrounding neighborhood, we calculated the percentages of park users of each race/ethnicity and compared these to the percentages of racial/ethnic groups residing in the neighborhood within a 1-mile radius of the park based on 2010 U.S. Census data. In the same parks, we administered an intercept survey to assess park users' self-reported use and perceptions of the park (N = 1872). We examined racial/ethnic differences in self-reported use and perceptions of parks using GEE models that adjusted for several individual- and park-level covariates. Hispanics comprised a disproportionate percentage of observed park users. Racial/ethnic groups generally did not differ in their self-reported park use and perceptions, except for the social context of park visits. In adjusted models, Hispanics had significantly higher odds of visiting with a child family member (OR = 1.44) and lower odds of visiting alone than non-Hispanic whites (OR = .55). Findings highlight Hispanics' greater propensity to use parks and indicate that parks may serve a communal purpose for Hispanics that they do not serve for other racial/ethnic groups.

We aimed to identify and categorize the types of policies that have been adopted to protect Americans from harmful exposures that could also be relevant for addressing diet-related chronic diseases. This article examines and categorizes the rationales behind government regulation. Our interest in the historical analysis is to inform judgments about how best to address newly emergent risks involving diet-related chronic disease within existing regulatory and information-based frameworks. We assessed exemplars of regulation with respect to harmful exposures from air, water, and food, as well as regulations that are intended to modify voluntary behaviors. Following the comparative analysis, we explored how exposures that lead to diet-related chronic diseases among the general population fit within models of regulation adopted for other comparable risks. We identified five rationales and five approaches that protect people from harmful exposures. Reasons for regulation include: protection from involuntary exposure to risk, high risk of death or chronic illness, ubiquity of risk, counteraction to limit compulsive behaviors, and promotion of population health. Regulatory approaches include: mandatory limits on use, mandatory limits on exposure, mandatory controls on quality, mandatory labeling, and voluntary guidance. In contrast to the use of mandates, the prevention of diet-related chronic diseases thus far has largely relied on information-only approaches and voluntary adoption of guidelines. There is ample precedent for mandatory regulatory approaches that could address harms related to exposure to unhealthy diets, but several barriers to action would need to be overcome., (© 2018 Society for Risk Analysis.)

Because restaurants routinely serve food with more calories than people need, dining out represents a risk factor for overweight, obesity, and other diet-related chronic diseases. Most people lack the capacity to judge the caloric content of food and there is limited evidence that people make use of calorie-labeling information when it is available. Standardized portion sizes would not preclude people from eating as much as they want, but would make the amount they are getting fully transparent. We describe the potential benefits and means of implementing a system of standardized portion sizes that might facilitate a healthier diet among the US population.

Purpose: Parks offer a free option for physical activity in many communities. How much time people spend using parks and the contribution that parks makes to their physical activity is not known. This study describes patterns of park use and physical activity among a diverse adult sample., Methods: From five US states, 248 adults enrolled in or near 31 study parks. Participants wore a global positioning system (GPS) monitor (Qstarz BT-Q1000X) and an ActiGraph accelerometer (GT1M) concurrently for 3 wk. Parks were mapped from local and national park shape files. Park visits and travel to and from the parks were derived from the objective data., Results: Participants visited parks a median of 2.3 times per week, and park visits lasted a median of 42.0 min. Overall, participants engaged in a median of 21.7 min·d-1 of moderate activity and 0.1 min·d-1 of vigorous activity, with an average of 8.2% of all moderate and 9.4% of all vigorous activity occurring within the parks. Among those with at least one park visit (n = 218), counts per minute, moderate, moderate-to-vigorous physical activity (MVPA), number and time in MVPA bouts per day, and sedentary behavior were all higher on days when a park was visited compared with days when a park was not visited. Considering several definitions of active travel, walking or bicycling to and from the park added an additional 3.7-6.6 mean minutes of MVPA per park visit., Conclusions: Parks contributed as a place and destination for physical activity but were underused. One of the next steps in this line of inquiry is to understand characteristics of parks used more often as a place and destination for physical activity.

Away-from-home foods are regulated with respect to the prevention of food-borne diseases and potential contaminants, but not for their contribution to dietary-related chronic diseases. Away-from-home foods have more calories, salt, sugar and fat, and include fewer fruits and vegetables than recommended by national nutrition guidelines. Thus, frequent consumption of away-from-home foods contributes to obesity, hypertension, diabetes, heart disease, and cancer. In light of this, many localities are already adopting regulations or sponsoring programs to improve the quality of away-from-home foods. We review the rationale for developing nutritional performance standards for away-from-home foods in light of limited human capacity to regulate intake or physiologically compensate for a poor diet. We offer a set of model performance standards to be considered as a new area of environmental regulation. Models for voluntary implementation of consumer standards exist in the environmental domain and may be useful templates for implementation. Implementing such standards, whether voluntarily or via regulations, will require addressing a number of practical and ideological challenges. Politically, regulatory standards contradict the belief that adults should be able to navigate dietary risks in away-from-home settings unaided., (© 2012 The Authors. obesity reviews © 2012 International Association for the Study of Obesity.)

Background: Since resources are limited, selecting the most promising targets for obesity interventions is critical. We examined the relative associations of physical activity, fruit and vegetable consumption and 'junk food' consumption with BMI and the prevalence of relevant policies in school, work, food outlets and health-care settings., Methods: We conducted intercept surveys in three low-income, high-minority California communities to assess fruit, vegetable, candy, cookie, salty snacks and sugar-sweetened beverage consumption and self-reported height, weight and physical activity. We also assessed relevant policies in selected worksites, schools and health-care settings through key informant interviews., Results: Data were collected from 1826 respondents, 21 schools, 40 worksites, 14 health-care settings and 29 food outlets. The average intake of salty snacks, candy, cookies and sugar-sweetened beverages was estimated at 2226 kJ (532 kcal) daily, 88% higher than the US Department of Agriculture/Department of Health and Human Services guidelines recommend. Energy from these sources was more strongly related to BMI than reported physical activity, fruit or vegetable consumption. Policies to promote healthy eating and physical activity were limited in worksites. Fruits and vegetables were less salient than junk food in community food outlets., Conclusion: Targeting consumption of salty snacks, candy cookies and sugar-sweetened beverages appeared more promising than alternative approaches.

Background: Socioeconomic status (SES) has well known associations with a variety of health conditions and behaviors in adults but is unknown in adolescents., Methods: Multilevel analysis was conducted to examine the associations between individual and neighborhood-level measures of SES and physical activity and body mass index in a sample of 1554 6th grade girls selected at random from 36 middle schools across 6 geographic regions in the United States that participated in the Trial of Activity for Adolescent Girls (TAAG). Data on parental education and employment, and receipt of subsidized school lunch were collected by questionnaire. Neighborhood-level SES was measured by the Townsend Index. Nonschool physical activity levels were measured by accelerometer and type, location and context was measured using a 3 day physical activity recall (3DPAR)., Results: After controlling for race, lower parental education and higher levels of social deprivation were associated with higher BMI. In a model with both variables, effects were attenuated and only race remained statistically significant. None of the indices of SES were related to accelerometer measured physical activity. Bivariate associations with self-reported Moderate-Vigorous Physical Activity (MVPA) location and type (3DPAR) varied by SES., Conclusion: Among adolescent girls in the TAAG Study, the prevalence of overweight is high and inversely related to individual and neighborhood SES.

Background: Historically, the alcohol and tobacco industries have been the biggest users of outdoor advertising. However, the 1999 Master Settlement Agreement (MSA) outlawed tobacco billboards and transit furniture (e.g., bus, bench) ads, and the Outdoor Advertising Association of America (OAAA) has pledged to voluntarily eliminate ads for alcohol and tobacco within 500 feet of schools, playgrounds, and churches., Methods: Outdoor advertisements were observed (2004-2005) in a sample of urban census tracts (106 in pre-Katrina southern Louisiana and 114 in Los Angeles County) to evaluate tobacco and alcohol advertisers' compliance with the MSA and the OAAA Code of Industry Principles. Data were analyzed in 2007-2008., Results: More than one in four tobacco ads in Louisiana failed to comply with the MSA. In Los Angeles, 37% of alcohol ads and 25% of tobacco ads were located within 500 feet of a school, playground, or church; in Louisiana, roughly one in five ads promoting alcohol or tobacco fell within this distance. In Los Angeles, low-income status and the presence of a freeway in the tract were associated with 40% more alcohol and tobacco billboards near children. In Louisiana, each additional major roadway-mile was associated with 4% more tobacco ads-in violation of MSA-and 7% more small ads near schools, playgrounds, and churches; city jurisdiction accounted for 55% of MSA violations and more than 70% of the violations of OAAA guidelines., Conclusions: Cities must be empowered to deal locally with violations of the MSA. Legislation may be needed to force advertisers to honor their pledge to protect children from alcohol and tobacco ads.

Background: During the past 40 y, there has been a trend toward more eating away from home, increased food availability, the opportunity to order extra-large portion sizes, and general weight gain., Objective: Because shorter people need fewer calories than taller people to maintain their weight, our goal was to determine whether the body mass index (BMI)-height relation has changed over time., Design: Data are from 3581 nonpregnant women and 3091 men examined in the 1959-1962 National Health Examination Survey and 4651 nonpregnant women and 4691 men examined in the 2001-2004 National Health and Nutrition Examination Survey. We tested whether the relation between BMI and height has changed for men and women, after adjustment for other demographic changes., Results: In the past, on average, shorter American men and women had significantly higher BMIs than taller people. However, taller people have been increasing their BMI during the past 40 y at a faster rate than shorter people., Conclusions: This study documents that the obesity epidemic has changed the height-BMI relation. The data cannot identify causal pathways, and there are numerous explanations. A plausible hypothesis is that changes in the food environment may have eliminated constraints on weight gain for taller people that existed in a more calorie-constrained environment.

Objectives: To assess the accessibility and suitability of schools as recreational sites and to determine whether they are associated with young adolescent girls' weekend metabolic equivalent-weighted moderate-to-vigorous physical activity and body mass index (BMI)., Methods: We drew a half-mile (0.805 km) radius around the residences of participants in the Trial of Activity for Adolescent Girls (n=1556) in Maryland, South Carolina, Minnesota, Louisiana, California, and Arizona. We visited all schools and parks within the defined distance and documented their amenities and accessibility on Saturdays in Spring 2003. Staff gathered data on each girls' height and weight and used accelerometers to record weekend metabolic equivalent-weighted moderate-to-vigorous physical activity., Results: Schools represented 44% of potential neighborhood sites for physical activity. However, a third of schools were inaccessible on the Saturday we visited. Neighborhoods with locked schools were primarily non-white, older, more densely populated, and of lower socioeconomic status. Though there was no relationship between school accessibility on Saturdays and weekend metabolic equivalent-weighted moderate-to-vigorous physical activity, the number of locked schools was associated with significantly higher body mass index., Conclusions: The lack of relationship between metabolic equivalent-weighted moderate-to-vigorous physical activity and school accessibility may imply that young adolescent girls do not identify schools as recreational resources. However, due to the association between body mass index and locked schools, efforts to stem the obesity epidemic should include making schools more accessible.

A number of studies in recent years have identified both self-report and objectively measured accessibility of recreational facilities as important predictors of physical activity in youth. Yet, few studies have: (1) examined the relationship between the number and proximity of objectively measured neighborhood physical activity facilities and respondents' perceptions and (2) compared objective and self-report measures as predictors of physical activity. This study uses data on 1,367 6th-grade girls who participated in the Trial of Activity for Adolescent Girls (TAAG) to explore these issues. Girls reported whether nine different types of recreational facilities were easily accessible. These facilities included basketball courts, golf courses, martial arts studios, playing fields, tracks, skating rinks, swimming pools, tennis courts, and dance/gymnastic clubs. Next, geographic information systems (GIS) were used to identify all the parks, schools, and commercial sites for physical activity located within a mile of each girl's home. These sites were then visited to inventory the types of facilities available. Girls wore accelerometers to measure their weekly minutes of non-school metabolic equivalent weighted moderate-to-vigorous physical activity (MW-MVPA). The number of facilities within a half-mile of girls' homes strongly predicted the perception of easy access to seven out of nine facility types. Both individual facility perceptions and the total number of facilities perceived were associated with increased physical activity. For each additional facility perceived, girls clocked 3% more metabolic equivalent weighted moderate-to-vigorous physical activity (p < 0.001). Although girls tended to record 3% more of this kind of physical activity (p < 0.05) per basketball court within a mile of their homes, objective facility measures were otherwise unrelated to physical activity. The results from this study suggest that raising the profile of existing facilities may help increase physical activity among adolescent girls.

Background: Despite substantial evidence for neighborhood characteristics correlating with walking, so far there has been limited attention to possible practical implications for neighborhood design. This study investigates to what extent design guidelines are likely to stimulate walking., Methods: Four of the New Urbanism Smart Scorecard criteria and two other measures were tested for their influence on walking. Data were obtained from the 1995 National Personal Transportation Survey, U.S. Census 2000, and InfoUSA. Propensity-score methodology was used to control for potential confounders., Results: Higher levels of business diversity and higher percentages of four-way intersections were associated with more walking. For example, the odds ratio (OR) for walking in a neighborhood with four business types present compared to three business types was 1.24 (confidence interval [CI] 1.07-1.44) and neighborhoods with 50%-74% four-way intersections had an OR for walking of 1.4 (CI 1.09-1.78) relative to those with 25%-49% four-way intersections. The effects of housing density on walking are mixed. Higher parking pressure and older median housing age did not significantly affect walking after covariate adjustment. Block length did not appear to be associated with walking., Conclusions: When considering the New Urbanism Smart Scorecard from the perspective walking, some, but not all, of its criteria that appear to have a correlation with walking are likely to be useful for designing walkable communities.

Relative to the magnitude of the epidemic, government funds available for HIV prevention are scarce. To optimize use of funds, we applied a mathematical model of the cost of HIV prevention interventions using national data on HIV risk-group size and HIV prevalence. This procedure suggested an allocation of funds across nine interventions to potentially prevent an estimated 20,000 infections annually, compared with the estimated 7,300 infections potentially prevented through four interventions now recommended by the Centers for Disease Control and Prevention (CDC). The optimal allocation will involve a combination of intensive interventions for high-prevalence populations and inexpensive large-scale interventions for lower-prevalence populations.

Objective: Communities need to identify cost-effective interventions for HIV prevention to optimize limited resources., Methods: The authors developed a spreadsheet tool using Bernoulli and proportionate change models to estimate the relative cost-effectiveness for 26 HIV prevention interventions including biomedical interventions, structural interventions, and interventions designed to change risk behaviors of individuals. They also conducted sensitivity analyses to assess patterns of the cost-effectiveness across different populations using various assumptions., Results: The 2 factors most strongly determining the cost-effectiveness of the different interventions were the HIV prevalence of the population at risk and the cost per person reached. In low-prevalence populations (eg, heterosexuals) the most cost-effective interventions were structural interventions (eg, mass media, condom distribution), whereas in high-prevalence populations (eg, men who have sex with men) individually focused interventions to change risk behavior were also relatively cost-effective. Among the most cost-effective interventions overall were showing videos in STD clinics and raising alcohol taxes. School-based HIV prevention programs appeared to be the least cost-effective. Needle exchange and needle deregulation programs were relatively cost-effective only when injection drug users have a high HIV prevalence., Conclusions: Comparing estimates of the cost-effectiveness of HIV interventions provides insight that can help local communities maximize the impact of their HIV prevention resources.

Objective: To study the association between objective measures of suburban sprawl and chronic medical conditions and mental health disorders in the USA., Methods: Cross-sectional analysis of survey data merged with objective measures of suburban sprawl. Outcomes are self-reported medical conditions, mental health disorders and health-related quality of life., Results: Sprawl significantly predicts chronic medical conditions and health-related quality of life, but not mental health disorders. An increase in sprawl from one standard deviation less to one standard deviation more than average implies 96 more chronic medical problems per 1000 residents, which is approximately similar to an aging of the population of 4 years., Conclusions: A robust association between sprawl and physical (but not mental) health suggests that suburban design may be an important new avenue for health promotion and disease prevention.

We examined the association of adolescent obesity with participation in sports among 5489 low-income, inner city public high school students. Among inner city youth 28.5% of males and 33.7% of females were overweight and 15.9% of boys and 16.4% of girls were obese. For both males and females, participation in an increasing number of athletic activities was associated with lower (body mass index) BMI after controlling for age, grade, and playing football. While youth with lower BMI might be more likely to participate in sports, after school sports are a potential opportunity for prevention of obesity in adolescents.

In an urban school district, 636 students in grades 9-12 were tested for Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction assays using specimens collected for routine urinalyses during sports physical examinations. Chlamydia and gonorrhea prevalences were 2.8% and 0.7% among males, and 6.5% and 2.0% among females, respectively. Among athletes infected with either sexually transmitted disease (STD), 93.1% reported no symptoms, and treatment was documented for 75.9%. Sports physicals offered a unique opportunity to screen and treat adolescents for STDs and to provide STD-prevention counseling.

Objectives: We explored the relationship between boarded-up housing and rates of gonorrhea and premature mortality., Methods: In this ecological study of 107 US cities, we developed several models predicting rates of gonorrhea and premature death before age 65 from all causes and from specific causes. We controlled for race, poverty, education, population change, and health insurance coverage., Results: Boarded-up housing remained a predictor of gonorrhea rates, all-cause premature mortality, and premature mortality due to malignant neoplasms, diabetes, homicide, and suicide after control for sociodemographic factors., Conclusions: Boarded-up housing may be related to mortality risk because of its potential adverse impact on social relationships and opportunities to engage in healthful behaviors. Neighborhood physical conditions deserve further consideration as a potential global factor influencing health and well-being.

Background: More than 40% of urban traffic fatalities are alcohol related and the rate of such fatalities varies more than 10-fold across U.S. cities. These variations might be explained by differences in local alcohol control policies and practices., Methods: We conducted a cross-sectional survey of state Alcohol Beverage Control agencies and local city police departments in 107 cities that participate in the National Highway and Traffic Safety Administration's Fatality Analysis Reporting System. We examined the association of alcohol control practices in 1997 and alcohol-related traffic fatalities per daily vehicle miles traveled, 1995-1997., Results: Ninety-seven (91%) cities participated. Regulations related to alcohol accessibility, licensure of alcohol outlets, disciplinary procedures of alcohol outlets, and enforcement of blood alcohol concentration laws were associated with lower rates of fatalities. Cities with 9 or fewer of the 20 regulations had 1.46-fold greater alcohol-related traffic fatality rates than cities with 15 or more of these regulations, representing 392 excess deaths annually. Beer consumption was found to be a potential mediator of the effect of regulations on traffic fatalities., Conclusions: Alcohol beverage regulations are associated with alcohol-related traffic fatalities. Localities should consider greater restrictions on alcohol accessibility, stricter disciplinary measures for violations, and stricter licensure requirements as a potential means to reduce alcohol-related traffic fatalities., (Copyright 2002 American Health Foundation and Elsevier Science (USA).)

Condom availability is a structural intervention that increases access to condoms. It is the most important strategy for the prevention of the sexual transmission of HIV/STDs in developing countries. While it is an integral component of many prevention programs, it is considered controversial in high school settings and its role in a variety of HIV/STD prevention interventions has been understudied, understated, and/or unacknowledged. Condom availability as an HIV/STD prevention strategy needs to be reprioritized and should be considered a critical foundation of all programs to prevent the sexual transmission of HIV.

This article investigates how children and their parents rate their parenting styles, and how this rating is associated with academic achievement, alcohol, and tobacco use. We surveyed students and their parents in two public school districts. A total of 386 matched parent-child pairs from eighth- and ninth-grade students were analyzed for parent and student classification of parents as authoritative, authoritarian, permissive, or mixed parenting styles. Agreement on parenting styles between parents and children was poor. Students perceived parents as less authoritative, less permissive and more authoritarian than parents considered themselves. High grades were associated with child and parent perception of higher authoritativeness, lower permissiveness, and lower authoritarianism. Child tobacco and alcohol use was associated with child perception of lower authoritativeness, and higher permissiveness while parent perception of parenting style was not associated with child substance use. This study provides further evidence that parenting styles and adolescents' perceptions of them are associated with child achievement and substance use. While we cannot determine whether child or parent perception of parenting style is more accurate, child perception is more strongly associated with grades and substance use than is parent perception. It is likely that parents would benefit from understanding how they are perceived by their children.

In 1986 the rate of infectious syphilis (primary and secondary) in Los Angeles County began to rise from previously stable levels of about 23.5 per 100,000 to peak at 55.6 per 100,000 in 1987. The incidence of congenital syphilis increased from 205 cases in 1987 to 575 cases in 1989. The county's Sexually Transmitted Disease Program instituted a disease-specific plan to address the epidemic. Factors considered in designing the program included the high morbidity and mortality associated with congenital infection, the existence of latent infection, self-limiting symptoms, and the availability of an inexpensive screening test and curative treatment. Policy changes implemented comprised expanded screening, expanded surveillance, increased contact tracing, and the initiation of condom promotion programs. To evaluate the relative effectiveness of Los Angeles County's syphilis control efforts, the epidemic curve for infectious syphilis was compared with trends in other urban areas. Although the rate of infectious syphilis climbed a year earlier in Los Angeles than in other cities, it returned to baseline levels when other cities' rates remained at epidemic levels.